Nursing curricular change is often an arduous process featuring a variety of barriers (Repsha et al., 2020). To reduce these barriers, curricular research recommends a variety of interventions, including phased-in changes, comprehensive support and mentorship for faculty, engaged leadership, creation of a change-positive culture, use of curricular champions, ongoing faculty development, and provision of guidelines (Hendricks & Wangerin, 2017; Repsha et al., 2020). Similarly, research into the transition from in-person to online or hybrid courses recommends having a clear vision for the course, use of institutional policies, providing mentorship, use of a course design team, and providing faculty with comprehensive technology resources (Haugen & Metcalf, 2018).
When urgent change is required due to external influences, such as the COVID-19 pandemic, these interventions may not be feasible. When change must occur rapidly, there is potential for a dramatic increase in stakeholder stress and a sense of disenfranchisement. Hence, those seeking to implement change must seek to understand and embrace the complexities of the situation, remain open to sources of anxiety, and identify meaningful ways to provide support to the affected faculty and students. The authors used chaos theory to understand the environment created by the rapid change necessitated by COVID-19. Chaos theory asserts that "the environment is patterned and yet nonlinear and unpredictable" and that periods of great change remain transitory; behavior will eventually cluster (Brockman et al., 2018, p. 411). This clustering is due to "attractors" in the environment that focus behavior around necessities (Demir et al., 2019, p. 1228). In the case of curricular change, the focal point may be student learning. Accordingly, in the midst of a volatile and unprecedented external environment, one can expect faculty to unify around a common good over the course of even the most dramatic transitions.
TRANSITION TO VIRTUAL SIMULATION
Amidst global concerns regarding COVID-19 and subsequent social distancing orders, immediate curricular changes in academic settings were necessary to continue meeting the educational needs of students. Following the rapid closure of clinical sites to students in all areas of health care, our four-year baccalaureate nursing program at a metropolitan, private, Jesuit university was faced with the unparalleled challenge of finding a clinical substitute for students. This program decided to use virtual simulation to enable students to progress in their program and add meaningful learning to their education. With only two weeks for this transition, the simulation center director organized a team of devoted stakeholders to identify possible solutions, evaluate virtual simulation offerings, and discuss implementation strategies in a manner that complied with the International Nursing Association for Clinical Simulation and Learning's standards of best practice.
Meetings were held via videoconference and led by the director of the simulation center and champion of this endeavor. A module was also set up on the university's learning management system under the simulation site for interested parties who were unable to attend the meetings or who wanted access to the meeting minutes and virtual simulation resources. Any faculty or staff who requested trial of the virtual programs of greatest interest were granted access at least a week prior to the final decision and purchase of the products.
The program decided to incorporate three virtual simulation platforms: two commercial products and one open-access site. These were integrated in a variety of combinations into a total of six unique courses and were purchased just prior to the official start to the next term. Following a university-wide decision, the term was delayed one week to support the conversion of course formats to remote. This allowed faculty to determine how to best incorporate virtual simulation into their courses, familiarize themselves with products, and enhance their simulation pre- and debrief skillset. Concurrently, the simulation team committed to provide extensive, remote support in accordance with the Jesuit pedagogy of cura personalis, which means care of the whole person.
The team's solution was to metamorphose into Virtual Simulation Doulas (Sim Doulas). The team chose the word doula to describe the sense of care and emotional encouragement required during this transition. The Sim Doulas were led by the simulation center director and included the center's simulation coordinator, technology support coordinator, operations coordinator, and the administrative assistant. Their goal was to undertake any nonteaching, administrative-style tasks related to virtual simulation and the product platforms, such as the creation of class sections, emailing access codes, and resolving minor technical issues. The director supported faculty with simulation training in accordance to the International Nursing Association for Clinical Simulation and Learning's standards of best practice, enabling faculty to focus on creating the best possible student-centered environment.
The Sim Doulas familiarized themselves with each of the platforms to understand common errors, navigation difficulties, and troubleshooting methods. They created a module in the learning management system to provide continually updated resources for faculty, including a Frequently Asked Questions page, site registration guides, technical support resources, and a description of their role. Most importantly, the Sim Doulas validated faculty, staff, and student emotions while remaining highly responsive and approachable to all stakeholders.
The Sim Doulas found the most efficient way to learn about the new products was to divide and conquer. Each one tried the platforms on different computer operating systems and browsers, at varying times of day, with and without auxiliary software programs. They deliberately varied their performance on simulation scenarios and imitated learners at different points in the nursing program. This division of labor accelerated the process of learning the systems' nuances and allowed the team to discover common user errors and best practices. Each Sim Doula took ownership of one or two clinical courses to provide tailored support to faculty throughout the term. Their role involved the initial setup of the courses on the applicable platforms, creating clinical sections, emailing access codes, troubleshooting in real time, providing remote support on an as-needed basis, and attending course videoconferences. The Sim Doulas also facilitated development of student evaluation surveys for the virtual simulations, data collection, and communication with product representatives. The team met regularly to share experiences, share knowledge, and grow a sense of community.
LESSONS LEARNED
The Sim Doulas' experience was different than what they had anticipated; imposter syndrome and uncertainty besieged the team as they simultaneously learned about and provided support for the systems. While most faculty and students responded positively to the Sim Doulas, some described an increase in their mental workload or feeling overwhelmed by the learning curve associated with virtual simulation. The Sim Doulas navigated these challenges by creating an internal community that enabled them to support one another.
Several skills had a positive impact on the process: transparent communication, the ability to be anticipatory, and adaptability. Transparent communication was important from the beginning, as information transfer is not always straightforward. The Sim Doulas discovered consistent communication with stakeholders was vital to keep everyone apprised of evolving information. The Sim Doulas also found it essential to be as anticipatory as possible. In addition to keeping informational documents, such as the Frequently Asked Questions page, updated and accessible, it was important to think both short and long term. Thus, the Sim Doulas managed administrative and academic workloads while concurrently preparing for future terms to avoid rushed development of courses.
Finally, the Sim Doulas found adaptability vital to traverse the obstacles caused by COVID-19, both during the transition to remote teaching and throughout the academic term. For example, as students and faculty faced increasing hardships and isolation during the COVID-19-imposed quarantine, frustrations sometimes overwhelmed coping capacity. By remaining flexible, positive, and striving to empower others, the Sim Doulas were better able to support others while maintaining a sense of community and spirit of cooperation.
As the situation evolves, the Sim Doulas remain integral to ongoing use of virtual simulations. In future terms, they envision providing one-on-one orientations for faculty new to virtual simulation and evaluating feedback regarding the virtual simulation experience of students and faculty. Cognizant that changes will be ongoing, the Sim Doulas remain open to expanding their role as needed.
RECOMMENDATIONS AND IMPLICATIONS
This team's experience indicates that a rapid and successful changeover to virtual simulation necessitates repurposing resources to provide continuous support to stakeholders throughout the learning process. Approaches should be tailored to the needs of the home institution and developed with faculty input. For maximum efficacy, a written resource guide for faculty is recommended. Finally, support systems ought to be established well in advance of implementation of new simulation products to familiarize stakeholders with the purpose and scope of new teaching-learning modalities.
The authors recommend the following topics for further exploration: the lived experience of rapid transition to remote clinical learning, analysis of faculty evaluations of remote clinical learning support, evaluation of student outcomes by comparing in-person and virtual simulation, and development of simulation guidelines specific to a remote learning environment.
REFERENCES